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Experts Advise At-Risk Diabetics to Begin Daily Aspirin Later

In a change, heart & diabetes groups push age threshold up from 40, to 50 for men, 60 for women. Three major medical groups have pushed upwards the recommended age at which diabetics should start taking low-dose aspirin to prevent a first heart attack or stroke.According to a joint statement by the American Heart Association, the American Diabetes Association and the American College of Cardiology, only male diabetics over 50 and female diabetics over 60 who are at risk for a heart attack or stroke should be taking aspirin as a preventive."Previously, the American Diabetes Association (ADA) recommended aspirin to prevent heart attacks and stroke in most people with diabetes over the age of 40," noted statement co-author Dr. M. Sue Kirkman, senior vice president for medical affairs and community information at the ADA. However, "more recent studies suggest that the benefits of aspirin are modest, and that aspirin likely would be best for people at very high risk of cardiovascular disease," she said.The experts defined an "increased risk of cardiovascular disease" in this case as a 10 percent risk of experiencing a heart attack and/or stroke over the next 10 years.
That means that, "those adults with diabetes at increased risk include most men over age 50, and women over age 60, who have one or more of the following additional major risk factors: smoking, hypertension, high cholesterol or a family history of premature cardiovascular diseases," Kirkman explained.According to the U.S. Centers for Disease Control and Prevention, people with diabetes are at three times the increased risk of cardiovascular events compared with people without diabetes. Among diabetics over 65, it's estimated that 68 percent will die from heart disease and 16 percent from stroke.
On the other side of the equation, the major adverse effects of long-term aspirin use include intracranial bleeding, which can lead to hemorrhagic stroke, and gastrointestinal bleeding.Still, daily low-dose aspirin -- the study authors suggest 75 to 162 milligrams -- can have real benefits in preventing cardiovascular events, another expert said."Taking low-dose aspirin to prevent heart disease is reasonable for adults with diabetes who are at increased risk of cardiovascular disease and not at increased risk for bleeding," said the statement's senior author, Dr. Michael Pignone, chief of the general medicine division and professor of medicine at the University of North Carolina.
"Aspirin should not be recommended for heart disease prevention in men and women at very low cardiovascular risk -- under 5 percent over 10 years," he added."People with diabetes should talk to their physicians about their cardiovascular risk and what they should be doing to try to reduce it to a manageable level," Pignone said. "This includes the decision about aspirin, but also blood pressure control, [cholesterol-lowering] statins, and smoking cessation."The clarification of aspirin use among diabetics is being made because the evidence regarding the benefit of aspirin in preventing a first heart attack or stroke has been mixed, the experts said.Most important, health care professionals should consider diabetic patients' absolute level of risk before recommending aspirin, Kirkman said."For those at relatively low risk, the risks of aspirin probably outweigh the potential benefits. For those at high risk, aspirin should be encouraged. The strong recommendation to use aspirin in patients with a history of cardiovascular events still stands," she said.Dr. Gregg C. Fonarow, professor of medicine and director of the Ahmanson-UCLA Cardiomyopathy Center at the University of California, Los Angeles, agreed that aspirin has a place in diabetes care."Low-dose aspirin is reasonable for patients with diabetes at higher cardiovascular risk, optional for those at intermediate risk, and generally not recommended in those patients at low cardiovascular risk," he said.Fonarow noted that even with these more limited recommendations, "there are many patients with diabetes who are high risk for cardiovascular events who are not receiving aspirin and other cardiovascular protective medications, such as statins, who could benefit from doing so, and who should consult with their physician."Another expert, Dr. Joel Zonszein, from the Clinical Diabetes Center, Montefiore Medical Center in New York City, said there's still a need for much stronger data on the issue.For now, Zonszein recommends giving patients at risk 325 milligrams of aspirin, "even though we have no [good] data," he said. "For patients who may have more of a bleeding problem, I give them the baby aspirin, but this is very biased, because we don't have good data."The statement is being published in three journals in 2010, Circulation, the Journal of the American College of Cardiology and Diabetes Care.